Treatment of Posttraumatic Stress Disorder An Assessment of the Evidence (2008) / Chapter Skim
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Pages 39-54
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Clinical trials and epidemiological studies of drug therapies and psychotherapies for veterans with PTSD and/or anxiety disorders 3. Studies other than meta-analyses, reviews, clinical trials, or epide miological studies that discuss drug therapies and psychotherapies for veterans with PTSD 4.
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Databases consulted include: • MEDLINE, • EMBASE (Excerpta Medica) , • PsycINFO, • Cochrane Database of Systematic Reviews, • Cochrane Controlled Trials Register, • National Technical Information Service (NTIS)
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• English language This review also included only primary research and no reanalyses of prior research. The committee was charged to "report on the highest levels of evidence available." Although the number of studies for some treatment modalities was small, in most cases randomized controlled trials were available for review. (For clarity, it should be noted that in the psychotherapy studies, the control was not placebo, but wait list, usual care, or a type of active control.)
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Additionally, information was abstracted on whether or not adverse events were reported, if meeting diagnostic criteria after treatment was reported, and if the study included veterans. REACHING CONCLUSIONS REGARDING THE EFFICACY OF TREATMENT MODALITIES The committee was charged with making conclusions about the strength of the available evidence for treatment modalities according to the following framework: 1.
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Assessing the Literature to Reach Conclusions The committee made an assessment of both the strength of the individual studies comprising the body of evidence, and the overall sufficiency of that body of evidence for judging treatment efficacy. The assessment of strength of individual studies was based on the degree to which the studies adhered to current scientific standards in design and analysis (see Criteria to Assess a Study's Quality in Box 2-2)
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is a major limitation that limited the study's usefulness to the committee in reaching its conclusion regarding efficacy. strength of the individual studies, the consistency of the effects among studies, and the degree to which the interventions, populations, and outcome measures used in those studies were deemed comparable. This overall sufficiency of the evidence for judging treatment efficacy was classified into the three categories (reflecting, as described above, the collapsed five conclusions listed in the committee's charge)
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A body of evidence that produced high confidence in both the presence and size of the effect would be "sufficient"; moderate confidence in the presence of an effect but substantial uncertainty about the size of the effect (e.g., whether it was clinically meaningful) would be "suggestive"; and uncertainty about both the effect and its size would be "inadequate." Another heuristic was to assess the robustness of the current evidence by imagining the impact of a high-quality moderate-size future study: if it were unlikely to impact conclusions about the presence or size of an effect, current evidence would be deemed "sufficient"; if it could meaningfully shift the strength of evidence, the current evidence pointing to an effect would be "suggestive"; and if it would effectively
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The evidence tables include population descriptors, sample size by arm and total, handling of missing data and dropout rates, information about blinding, PTSD outcome measure change data, loss of PTSD diagnosis data, and finally, a listing of a study's principal limitations. SUMMARY OF THE LITERATURE REVIEWED IN MAKING CONCLUSIONS The final set of studies reviewed by the committee consisted of 89 total, with 37 studies of pharmacotherapies and 52 studies of psychotherapies.
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Psychotherapy studies had lower dropout rates than pharmacotherapy studies (14 percent versus 32 percent) , and psychotherapies were more effective in reducing symptoms.
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The authors found no significant difference in comparing treatment against wait list or standard care. Harvey et al.
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The authors found that the studies varied in methodologic quality, and were generally small, most lacked assessor blinding, and had high rates of loss to followup. Fifteen of 16 studies showed positive treatment effects for EMDR.
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Rothbaum and colleagues found the evidence of effectiveness for exposure conclusive, and also found evidence of effectiveness for SIT and cognitive processing therapy. They found combined CBT approaches (such as exposure plus SIT)
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The chapters include abbreviated evidence tables with key information about studies that contributed to reaching conclusions about the evidence regarding the efficacy of each treatment modality. REFERENCES Bisson, J., and M
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. Cochrane Database Systematic Reviews (4)
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KEY for Tables 3-1 through 3-11: Arm = treatment condition PL = placebo DO = dropout rate PTSD outcome measures -- refer to list of ITT = intent-to-treat analysis acronyms in Appendix E for full name LOCF = last observation carried forward of measure Misc = miscellaneous S&NS assault or abuse = sexual and N/A = not available nonsexual assault or abuse NR = not reported Tx = treatment NS = not significant 54
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